I understand my fingerprint form may be provided to other Federal state or local agencies in conjunction with the application process and I consent to such disclosure. Consent For Fingerprint Check Part A I hereby authorize any investigator special agent or other duly appointed representative of the authorized Federal agency conducting my background investigation to receive any criminal history record information pertaining to me which may be in the files of any Federal state or local criminal justice agency. Name Last first middle initial Please print Home phone number Social Security Number Signature Date You must sign here Privacy Act Statement The Privacy Act Statement of 1974 requires that when we ask you for information we state our legal right to do so why we are asking for the information and how it will be used* We must also tell you what could happen if you do not provide it and whether your response is voluntary required to obtain a benefit or mandatory. Our legal right to ask for the information is 5 USC 301 and Executive Order 9397. We are asking for this information to investigate your background and determine your suitability for employment. Disclosure of the information may be made to Federal state and local agencies and judicial authorities as authorized by law. Violations or potential violations of law whether civil criminal or regulatory in nature may be reported to appropriate agencies that have the responsibility for investigating or prosecuting such violations or are charged with enforcing or implementing such laws. Your failure to complete the pre-appointment/post-appointment information on this form may mean that the required information cannot be obtained to determine your suitability and/or conduct an investigation* Without this information a determination as to your suitability for Federal employment cannot be made and may result in you not being considered for employment or a determination may be made that you are unsuitable for your position* Live Scan Screen Information Part B Middle Name Full Legal Middle Name. Do not use initials. If no middle name indicate by printing NMN. Maiden Name should be listed in Aliases block Last name First name Middle name Date of birth mm/dd/yyyy Position applying for Clerk Aliases for example maiden name or other last names used Male Race Female Eye color excluding colored contacts TRR/TSS Tax Examiner Contact Representative Sex Revenue Agent Data Transcriber Other specify Hair color A - Asian W - White/Latino BLK - Black HAZ - Hazel BAL - Bald RED - Red U - Unknown BLU - Blue MAR - Maroon SDY - Sandy BRO - Brown PNK - Pink BLN - Blond WHI - White GRN - Green XXX - Unknown I - Indian Native American Eskimo GRY - Gray Height feet and inches Weight pounds Place of Birth City State Country - if born in Mexico or Canada include state or province where born Resident address street number and name do not use P. O. Box City Form 12333 Rev* 7-2011 State Catalog Number 28289L publish. no. irs. gov ZIP code Department of the Treasury-Internal Revenue Service Security Entry and Tracking System SETS Activity Log For Personnel Office Use Only Name Applicant/Employee Reason for fingerprinting EOD or date entered new position POD Business Unit i*e* AWSS SBSE WAGE etc* Live Scan number SOI SON If courtesy print - please FAX servicing personnel office consent form within 24 hours Fingerprints Action Ink and Roll Forms Entered into Live Scan or SETS EE initials FP Taken by EE Name Phone number SETS Investigation package EE FP Taken by Courtesy Personnel Office Returned by EE Follow-up if applicable Review by QR BIO entered into live scan by SETS Applicant Record Built and type of investigation Transmitted/Mailed SETS update not allowed Return unaccept Returned Resubmitted CCT Received Prior Investigation New investigation not required Comments.
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